Insurance Enrollment Form
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1
2
3COLONIAL LIFE & ACCIDENT INSURANCE COMPANY, PO BOX 1365 COLUMBIA, SC 29202
ENROLLMENT FORM - GROUP TERM LIFE INSURANCE
Application Type: Initial Request
Late Applicant
Rehire
E4311049
Basic BCN: ____________________
Annual Enrollment Change in Status Increase Supplemental / Voluntary BCN: ____________
Note: If you DO NOT ENROLL for coverage for you or your dependent(s) during the initial enrollment period, and / or you
apply for coverage over any Guaranteed Issue amount, you will need to complete the Evidence of Insurability form.
SECTION 1: EMPLOYEE (APPLICANT) INFORMATION – Always complete
Proposed Insured Name (First, MI, Last)
Gender
Birthdate (
)
Social Security No.
mm/dd/yyyy
M
F
Home Address – Street
City
State
Zip Code
Employee ID/Payroll No.
Email Address
Home Phone No.
Business Phone No.
Date Employed
Occupation/Job Title
Annual Base
Hrs. Worked/
Employee Class
Salary
Week
Employer Name
Employer Address (Street-City-State-Zip)
Section/Dept. No.
701 N Church St, Jackson, NC 27845
Northampton County Schools
SECTION 2: COVERAGE INFORMATION – Always complete
Monthly
Coverage Elections
Plan Code
Face Amount
Premium
Basic (Employer) If multiple of salary, indicate multiple _______
8CZU
$10,000
$2.12
Employee If multiple of salary, indicate multiple _______
Spouse
Dependent Children
Is a suite being applied for? Yes No Rider Plan Code: __________
Employee Coverage is Supplemental / Voluntary
Total Premium
SECTION 3: SPOUSE/DEPENDENT CHILDREN INFORMATION – Complete only if applying for spouse and/or
dependent children coverage
Birthdate
Name (First, MI, Last)
Gender
Relationship
Social Security No.
(mm/dd/yyyy)
M
F
M
F
M
F
M
F
M
F
SECTION 4: BENEFICIARY INFORMATION – Employee only
Beneficiary’s Name (First, MI, Last)
Age
Benefit %
Relationship to Proposed
Social Security
Primary
Insured
No.
Contingent
Beneficiary’s Name (First, MI, Last)
Age
Benefit %
Relationship to Proposed
Social Security
Primary
Insured
No.
Contingent
GTL - EnrollP - NC
80162
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